title: Postoperative Dysphagia in laparoscopic paraesophageal hernia repair: the effect of distal esophageal angulation.
abstract: BACKGROUND
  Dysphagia following laparoscopic paraesophageal hernia repair is an uncommon but difficult problem that may be due to technical factors. We looked for an association between esophageal angulation after posterior crural repair and postoperative dysphagia.
  
  
  METHODS
  Patients undergoing paraesophageal hiatus hernia repair were identified from a prospectively maintained dedicated database. All patients underwent a standardized laparoscopic repair. Essentially the hernia sac was dissected from the mediastinum, a posterior hiatal repair was carried out with interrupted polyester sutures, and augmented with mesh on lay. A partial posterior fundoplication was then carried out. We used the number of posterior sutures as a proxy for anterior esophageal angulation. Quality-of-life data and dysphagia scores were recorded preoperatively, at 6 weeks postoperatively and 12 months postoperatively using validated instruments.
  
  
  RESULTS
  Between November 2004 and September 2010, 114 consecutive patients underwent paraesophageal hiatus hernia repair. There was 1 postoperative death in the series. Median age was 67 years (interquartile range, 59 to 77 y) and 90 (79%) were female. Median hospital stay was 3 days (interquartile range, 2 to 5 y). Follow-up data were available in 87 (76%) of patients at 6 weeks and 94 (82%) of patients at 12 months postoperation. Overall, there was a significant improvement in quality of life that was sustained out to 12 months (P<0.001). Dakkak dysphagia scores were significantly improved postoperatively. Improvement was sustained out to 12 months (P<0.001). Three patients underwent endoscopic esophageal dilation for dysphagia following surgery. There was no significant correlation between the number of posterior sutures used and dysphagia outcome. Specifically there was no association with overall Dakkak scores or change in Dakkak score.
  
  
  CONCLUSIONS
  Anterior angulation due to posterior hiatal repair does not result in worsening dysphagia, even in patients with large hiatal defects. A posterior repair should therefore remain the standard approach for hiatal closure.
authors.affiliation: Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, NSW, Australia.
authors.forename: Peter N
authors.initials: PN
authors.lastname: Stiven
authors.forename: Ross
authors.initials: R
authors.lastname: Hansen
authors.forename: Andrea
authors.initials: A
authors.lastname: Richardson
authors.forename: Steven
authors.initials: S
authors.lastname: Leibman
authors.forename: Garett S
authors.initials: GS
authors.lastname: Smith
mesh_terms: D000368:Aged; D003680:Deglutition Disorders / Q000209:etiology*; D004106:Dilatation / Q000379:methods; D004945:Esophagoscopy / Q000379:methods; D005260:Female; D006551:Hernia, Hiatal / Q000601:surgery*; D059685:Herniorrhaphy / Q000009:adverse effects* / Q000379:methods; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects* / Q000379:methods; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011182:Postoperative Care / Q000379:methods; D011446:Prospective Studies; D011788:Quality of Life; D013536:Suture Techniques; D016896:Treatment Outcome